Neonatal ICU Guideline for Apnea of Prematurity
1. All infants <30 weeks gestation and/or <1500 grams, admitted on any form of ventilation/noninvasive
ventilation, will be started on Caffeine Citrate. Patients not meeting this gestational age/weight criteria that
exhibit symptomatic apnea of prematurity can be started on Caffeine Citrate per neonatology discretion.
Dosing as follows: load with 20 mg/kg, maintenance 10 mg/kg/day.
2. If infant develops tachycardia, not attributed to any other cause, or becomes irritable while ventilated, consider
decreasing daily maintenance dose to 5 mg/kg. Dividing dose q 12 hours is not recommended due to the long
half-life of Caffeine.
3. Consider discontinuing Caffeine Citrate, if no significant events for 7 days beginning at 33 0/7 weeks PMA.
Significant events are defined as: apnea >20 seconds, bradycardia >10 seconds, periodic breathing with
desaturation >20 seconds, any events requiring stimulation or oxygen increase.
4. If an infant in room air begins having an increased number of self-correcting events following discontinuation of
Caffeine Citrate, place on smart monitor and download to determine need for resumption of Caffeine Citrate.
5. Consider stopping Caffeine Citrate on inpatient infants when they reach 37 weeks post-menstrual age (PMA),
even if on support.
6. Pulse oximeters should remain on all infants in room air and on/or off Caffeine Citrate, until discharge or 37
weeks PMA, to monitor for intermittent hypoxia.
7. Discharge Criteria as follows:
 Going home on caffeine and monitor-24 hours of no significant alarms - i.e., during sleep requiring
intervention. Place following in problem list: Download monitor 3-4 weeks following discharge. If infant on
Caffeine and download is without events, discontinue caffeine. All infants will remain on monitor with
repeat download at 44 weeks PMA, if remains without events, discontinue monitor.
 Going home on monitor without caffeine-24 hours of no significant alarms - i.e., during sleep requiring
intervention. Place following in problem list: Download monitor at 44 weeks PMA, if download normal,
discontinue monitor.
 Going home on neither but were on caffeine during hospital stay-7 days of no significant alarms - i.e., during
sleep requiring intervention. Documentation by neonatologist is required for decision to discharge prior to 7
days.
OnlineTM, L. C. (2015). Pediatric & Neonatal Lexi-Drugs OnlineTM, Hudson, Ohio: Lexi-Comp.
Rhein, L. (2015). Caffeine for premature infants: When to start and when to stop. Speech.
Rhein, L. M., Dobson, N. R., Darnall, R. A., Corwin, M. J., Heeren, T. C., Poets, C. F., ... & White, R. D. (2014).
Effects of caffeine on intermittent hypoxia in infants born prematurely: a randomized clinical trial. JAMA
Pediatrics, 168(3), 250-257.
Initiated: 11/5/15
Reviewed: 2/11/16
Revised: 2/18/16